- Date
- 2/15/2024
- Report number
- 00313705-AP-266069
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- On or about February 15, 2024, Alleged Perpetrator 2 (AP2), Alleged Perpetrator 3 (AP3), and Alleged Perpetrator 4 (AP4) transferred Alleged Victim (AV) against AV's wishes which led to a physical altercation. Based on facility documentation and interviews, at time of incident, AV was sitting in a chair in another resident's bathroom. AV became agitated and physically aggressive towards AP3 when AP3 asked AV to leave the bathroom and/or be escorted by AP3. Instead of leaving AV alone, AP3 went and got AP2 and AP4 to assist in getting AV out of the bathroom. Even though AV was swinging not wanting to stand up, AP2 and AP4 placed AV into a wheelchair that AP3 was holding. AV is care planned as independent with transfers and mobility. AP2, AP3, and AP4 forcibly removed AV in a rough manner and handled AV as a two-person transfer when AV is not care planned as a two person assist. AP2, AP3, and AP4 forcible actions caused a physical altercation between AV, AP2, AP3, and AP4 resulting in emotional harm and unreasonable discomfort for AV. AP2's, AP3's, and AP4's actions are considered physical abuse against AV. AP2, AP3, and AP4 failed to allow AV to exercise his/her resident rights by failing to treat AV with respect and dignity, failing to allow AV to refuse service, and failing to allow AV to receive services in a manner that protects privacy and dignity. AP2, AP3, and AP4 moderately violated AV's resident rights, which caused AV emotional harm. The facility is responsible for the supervision, training, and overall conduct of AP2, AP3, and AP4 when AP2, AP3, and AP4 are acting within the scope of his or her employment duties. The facility failed to provide AV with a safe home-like environment resulting in an incident in which the facility's staff moderately violated AV's resident rights, which constitutes abuse and is considered neglect of care.
- Sanction
- RCFCP25-00902 $1125.00 fine assessed